Advanced Health Care Of Paradise
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 3455 Pecos-mcleod Interconnect, Las Vegas, Nevada 89121
- CMS Provider Number
- 295107
- Inspections on file
- 19
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Advanced Health Care Of Paradise during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was discharged without documented evidence that they were presented with or assisted in choosing among post-acute care providers, as required by their care plan. Staff interviews revealed that while a form existed for selecting the facility's preferred home health agency, there was no consistent documentation that residents were informed of other options or that their preferences were considered.
A facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident with a right hip fracture and syncope, whose Medicare Part A services ended. The resident was discharged without documented evidence of receiving the NOMNC letter, which was expected to be provided three days before the end of benefits. The facility's policy required the NOMNC to be delivered at least two days before services end, with the original signed document retained in the file.
The facility failed to implement care plan interventions for several residents, including the absence of an air mattress for a resident at risk for pressure ulcers, delayed midline dressing changes for two residents, lack of feeding assistance for two residents with malnutrition, and delayed enema administration for a resident with bowel care needs. These deficiencies indicate lapses in following prescribed care protocols.
A facility failed to accurately document care for residents, including the application of antimicrobial wipes, wound care, and midline dressing changes. For one resident, CHG wipes were not applied as ordered, and the RN documented care without verification. Two residents had discrepancies in wound care documentation, with dressings not changed as recorded. Midline dressing changes for two residents were also inaccurately documented, with observed dressings not matching recorded dates. These failures went against professional standards and could compromise patient safety.
Two residents in a facility were not provided with the required one-on-one feeding assistance despite physician orders and clear signage indicating the need. One resident, with metabolic encephalopathy and dementia, was left with untouched meal trays and not seated in a chair as instructed, while another resident with severe malnutrition was incorrectly assumed to be independent in eating. The lack of adherence to feeding assistance orders placed both residents at risk for significant weight loss and malnutrition.
A resident with a multidrug-resistant fungal infection did not receive prescribed Chlorhexidine (CHG) wipes as ordered. The RN documented the application without verifying if CNAs performed the task, leading to discrepancies in the treatment administration record. The DON confirmed this was inappropriate and could be considered an alteration of medical records.
A facility failed to follow a physician's order for an air mattress for a resident at risk for pressure ulcers, and did not provide wound care as per orders for two residents. The air mattress was not delivered or placed, despite documentation indicating otherwise. Additionally, wound care treatments were missed and inaccurately documented, with staff pre-signing treatments that had not been administered. The Director of Nursing acknowledged the discrepancies and the unacceptable practice of signing off on unadministered treatments.
A resident with a history of ulcerative colitis and diverticulitis did not receive appropriate bowel care as per the facility's protocol. Despite a physician's order for a Fleet Enema on the fifth day without a bowel movement, the enema was not administered by the ninth day. The resident's family was not informed about the bowel protocol or the enema order, and the KUB test results were not provided upon request. The facility's failure to follow the bowel protocol led to a deficiency in care.
The facility failed to provide one-on-one feeding assistance for two residents, as ordered by physicians, leading to a risk of significant weight loss and malnutrition. One resident, with metabolic encephalopathy and dementia, was left with untouched meal trays and no staff assistance, despite being dependent on staff for eating. Another resident, with dementia and severe malnutrition, also did not receive the required assistance. The lack of compliance with feeding orders was not communicated to the Registered Dietician, potentially leading to significant weight loss.
The facility failed to ensure proper justification and maintenance of midline catheters for two residents, leading to potential risks of complications. One resident had a midline catheter with no physician's clarification order, and the dressing was not changed as documented. Another resident's midline dressing was also not changed as documented, despite being used for IV administration. The Director of Nursing acknowledged the lack of a specific midline policy and confirmed the facility followed the PICC Dressing Change policy.
A facility failed to implement proper infection control measures for a resident with an indwelling urinary catheter and intravenous midline catheter. Despite a physician's order for enhanced barrier precautions, a therapist did not wear a gown while providing care, only using gloves. This was confirmed by a registered nurse and the infection preventionist nurse, who stated that both gloves and gowns were required according to the facility's policy and CDC guidelines.
The facility failed to ensure proper dialysis care and communication for two residents, leading to potential cross-contamination, inadequate infection control, and lack of monitoring for dialysis-related complications.
The facility failed to obtain a physician order and implement a care plan for a resident's wrist splint. The resident was admitted with a wrist fracture and had a splint in place, but the necessary orders and care plan were not documented or transcribed, leading to the deficiency.
The facility failed to ensure a physician's order for IV insertion and care for a resident admitted with urinary tract infection, sepsis, and dehydration. The IV heplock was old and undated, and there was no documented evidence of a physician's order for the IV insertion or related care.
The facility failed to follow the physician's order for a resident's oxygen administration, resulting in the resident receiving 4 LPM instead of the prescribed 2 LPM. The order lacked clarity on whether the O2 should be continuous or as needed, and titration parameters were not specified. Both the RN and DON acknowledged the oversight.
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 6.25%. One incident involved a nurse administering a standard iron tablet instead of the prescribed delayed-release form, and another involved a nurse applying only one Lidocaine patch instead of the two ordered. The DON acknowledged the errors and emphasized the need for verifying orders prior to administration.
The facility failed to secure medication carts and protect resident information. Two instances were observed where medication carts were left unlocked and unattended, with computer screens displaying resident information visible to passersby. Both nurses involved acknowledged the importance of securing the carts and screens.
The facility failed to discard expired thickened orange juice containers, allowed a Cook to eat next to the food tray line, observed a Dietary Aide touching their face with gloved hands while handling food, and did not refill a soap dispenser in the kitchen timely. These actions could have led to contamination and foodborne illnesses.
The facility failed to implement TBP and ensure proper use of PPE for a resident with ESBL and VRE, and did not maintain hand sanitizer dispensers in resident rooms. The resident was transported without adherence to TBP protocols, and multiple hand sanitizer dispensers were observed empty, compromising infection control practices.
The facility failed to document resident council meetings and grievances, as required by their policies. Interviews with the Administrator and a CNA revealed that no meeting minutes were taken, and the facility did not maintain a formal grievance log, despite starting resident council meetings in 2023.
Failure to Document Resident Choice in Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident was appropriately discharged in accordance with their needs and preferences. The resident, who had diagnoses including spondylosis, type 2 diabetes mellitus, hypothyroidism, and hypertension, was admitted with a care plan that required coordinated discharge planning to their home with family. The facility was responsible for assisting the resident and their support person in locating and coordinating post-discharge services, such as home health care, durable medical equipment, oxygen, prescriptions, and other support services. However, documentation revealed that the facility did not provide evidence that the resident was presented with options or assisted in choosing a post-acute care provider that best suited their goals, preferences, needs, and circumstances. Interviews with facility staff indicated that while a form existed for residents to select the facility's preferred home health agency, there was no documented evidence that the resident in question was given a choice or presented with alternative providers. Other residents had signed referral forms for the facility's home health agency, but some did not recall signing them, and the facility did not maintain a list of home health agency providers to offer as options. The Director of Nursing and the Administrator both acknowledged that documentation of discharge planning discussions and options provided was lacking or not consistently recorded in the resident's notes.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) letter to a resident, identified as Resident #99, who was admitted with diagnoses including a fall, right hip fracture, and syncope. The resident's Medicare Part A skilled services episode began on August 30, 2024, and the last covered day for Part A services was September 18, 2024. The resident was discharged home on September 19, 2024. However, the medical record lacked documented evidence that the NOMNC letter was provided to the resident or their representative. On March 19, 2025, the facility's Case Manager was unable to produce evidence that the NOMNC letter was given to the resident. The facility's Administrator confirmed that it was expected to follow CMS guidelines and provide the NOMNC letter three days prior to the end of benefits. The facility's policy stated that the NOMNC should be delivered at least two days before Medicare-covered services end, and the original signed document must be retained in the beneficiary's file. This deficiency resulted in non-compliance with Medicare requirements, potentially affecting the resident's ability to make informed decisions regarding their coverage and care.
Failure to Implement Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for several residents, leading to deficiencies in care. One resident, who was at moderate risk for pressure ulcers, did not receive an air mattress as ordered by the physician. Despite the order being documented and verified in the treatment administration record, the air mattress was not placed on the resident's bed, and the wound care nurse did not ensure its delivery or placement. Additionally, a registered nurse documented the air mattress placement without verifying its presence, indicating a lapse in following the care plan. Another resident with a midline catheter did not receive timely dressing changes as per the physician's order. The dressing was observed to be loose and had not been changed for eight days, despite the care plan specifying weekly changes. Similarly, another resident with a midline catheter also did not receive the required dressing change for nine days. This lack of adherence to the care plan for midline care could potentially compromise the residents' health. Furthermore, two residents with nutritional care plans requiring one-on-one feeding assistance did not receive the necessary support during meal times. Observations revealed that staff members were not present to assist these residents, despite their documented need for assistance due to severe protein-calorie malnutrition. Additionally, a resident with a bowel and bladder care plan did not receive an enema as scheduled, resulting in a delay of four days beyond the prescribed intervention. These failures in implementing care plan interventions highlight significant gaps in the facility's adherence to care protocols.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to ensure accurate documentation of care provided to residents, leading to potential compromises in patient safety. For Resident #92, there was a physician order to apply Chlorhexidine (CHG) wipes daily due to a Candida auris infection. However, the treatment administration record (TAR) was inaccurately signed by a Registered Nurse (RN) without verifying the application by Certified Nursing Assistants (CNAs). The CNAs confirmed that regular wipes and soap were used instead of CHG wipes on certain days, and the RN later documented extemporaneous entries in the TAR, which were not present during the initial review. For Residents #17 and #21, there were discrepancies in the documentation of wound care. Both residents had orders for specific wound care treatments, but observations revealed that the dressings on their heels were not changed as documented in the TAR. The wound care nurse admitted to pre-signing treatments before actual administration, leading to inconsistencies between the documented care and the actual condition of the dressings. This practice was acknowledged by the Director of Nursing (DON) as going against the facility's adopted standards of practice. Additionally, there were issues with the documentation of midline dressing changes for Residents #17 and #21. The dressings observed on both residents did not match the dates of documented care in the Medication Administration Record (MAR). The DON confirmed that nurses were not permitted to sign off on treatments without administering them, and the discrepancies in documentation were against professional standards of practice. These documentation failures had the potential to lead to errors in care and hinder continuity of treatment.
Failure to Provide Required Feeding Assistance
Penalty
Summary
The facility failed to provide necessary one-on-one feeding assistance to two residents, Resident 21 and Resident 11, who were assessed to require such assistance. Resident 21, diagnosed with metabolic encephalopathy, dementia, and a history of craniotomy, was observed on multiple occasions with meal trays left untouched and no staff present to assist with feeding. Despite a physician's order for one-on-one feeding assistance and instructions to sit the resident up in a chair during meals, these directives were not followed. Certified Nursing Assistants (CNAs) reported that the resident refused to eat, defining refusal as a lack of response from the resident, and did not seek help from other staff or inform the nurse of the refusal. Similarly, Resident 11, with diagnoses including unspecified dementia and severe protein-calorie malnutrition, was also not provided with the required one-on-one feeding assistance. Although a physician's order was in place due to the resident's increased fatigue and poor meal intake, the CNA assigned to the resident was unaware of this requirement and incorrectly believed the resident was independent with eating. This oversight resulted in the resident consuming only a minimal portion of their meal. The Director of Nursing (DON) and Registered Dietician (RD) confirmed the lack of adherence to the feeding assistance orders and the potential impact on the residents' nutritional status. The RD noted that Resident 21 had experienced a two-pound weight loss, which, while not yet significant, could become so if interventions were not implemented. The facility's failure to follow physician orders and ensure proper feeding assistance placed the residents at risk for significant weight loss and malnutrition.
Failure to Administer Prescribed Antimicrobial Wipes
Penalty
Summary
The facility failed to ensure that prescribed antimicrobial wipes were used for the treatment of a multidrug-resistant fungal infection in a resident. The resident, who was admitted with multiple diagnoses including dementia and a Candida auris infection, had a physician order for daily application of Chlorhexidine (CHG) wipes. However, the treatment administration record (TAR) indicated discrepancies in the application of these wipes. On several occasions, the wipes were not applied as ordered, and regular wipes with soap and water were used instead. The RN responsible for documenting the application of the CHG wipes admitted to charting the administration without verifying if the CNAs had actually performed the task. The RN later made extemporaneous entries in the TAR to reflect the actual application status after discovering the oversight. The Director of Nursing confirmed that these actions were inappropriate and could be considered an alteration of medical records. This deficiency in care had the potential to increase the risk of complications for the resident and compromise the overall quality of care within the facility.
Deficiency in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that a physician's order for an air mattress was followed for a resident, leading to a deficiency in pressure ulcer care. The resident, who was at moderate risk for pressure ulcers due to multiple co-morbidities, did not have the ordered air mattress in place. Despite the physician's order and care plan specifying the need for an air mattress, it was not delivered or placed on the resident's bed. The wound care nurse acknowledged the oversight and the failure to verify the placement of the air mattress, which was documented as verified in the treatment administration record without actual confirmation. Additionally, the facility did not provide wound care treatment as per physician's orders for two residents. One resident reported inconsistent care for heel ulcers and a coccyx wound, with the treatment administration record showing missed wound care on several dates. The registered nurse and wound care nurse both acknowledged the discrepancies in documentation and the failure to administer wound care as scheduled. The wound care nurse admitted to pre-signing treatments that had not yet been administered, leading to inaccurate documentation. For another resident, the facility also failed to administer wound care as ordered, with the treatment administration record indicating missed treatments. The wound care nurse and registered nurse both confirmed the lack of documentation and the practice of pre-signing treatments. The Director of Nursing acknowledged the unacceptable practice of signing off on treatments that were not administered and the misalignment between observed dressings and documented care.
Failure to Follow Bowel Protocol for Constipated Resident
Penalty
Summary
The facility failed to follow its bowel protocol for a resident who was constipated, leading to a deficiency in care. The resident, who had a history of ulcerative colitis and diverticulitis, had not had a bowel movement since March 11, 2025. Despite having a physician's order for a Fleet Enema to be administered on the fifth day without a bowel movement, the enema was neither offered nor administered by March 20, 2025, which was nine days without a bowel movement. The facility's bowel protocol, known as the Bowel Brigade, was not followed, as the resident did not receive the prescribed interventions, including Milk of Magnesia and Dulcolax suppository, in a timely manner. The resident's family member, who visited daily, expressed concerns about the lack of bowel movements and was not informed about the bowel protocol or the physician's order for an enema. The family member was also not provided with the results of a KUB test, which showed mild increased feces throughout the colon, despite requesting them. The Infection Preventionist confirmed that the enema was not administered as per the protocol, and the Director of Nursing acknowledged that the facility's standing orders were not followed. This oversight placed the resident at risk for bowel complications.
Failure to Provide 1:1 Feeding Assistance
Penalty
Summary
The facility failed to follow physician's orders to provide one-on-one feeding assistance for two residents, leading to a risk of significant weight loss and malnutrition. Resident 21, who was admitted with diagnoses including metabolic encephalopathy and dementia, was observed on multiple occasions with meal trays left untouched and without staff assistance, despite a clear order for 1:1 feeding assistance. The resident was dependent on staff for eating, and the lack of assistance was attributed to CNAs being too busy or shy to ask for help. The resident's condition improved when seated in a chair, but this intervention was not consistently implemented. Similarly, Resident 11, diagnosed with unspecified dementia and severe protein-calorie malnutrition, was also not provided with the required 1:1 feeding assistance. The resident was observed with a meal tray in front but no staff present to assist, despite a physician's order due to the resident's increased fatigue and poor meal intake. The DON confirmed that the physician's orders were not followed, and the CNAs failed to report meal refusals to the nurse, preventing further attempts to assist the residents. The Registered Dietician noted that both residents had issues with alertness and poor consumption, necessitating the 1:1 feeding assistance. The RD was not informed of the lack of compliance with the feeding orders, which could potentially lead to significant weight loss. The facility's policy required necessary services to maintain good nutrition for residents unable to carry out activities of daily living, but this was not adhered to in the cases of Residents 21 and 11.
Deficient Midline Catheter Management for Two Residents
Penalty
Summary
The facility failed to ensure proper justification and maintenance of midline catheters for two residents, leading to potential risks of complications such as occlusion and infection. Resident 17 was admitted with a midline catheter in the right upper arm, but there was no documented evidence of a physician's clarification order regarding whether the midline should be maintained or removed. The midline dressing was observed to be dated 03/10/2025, with ends coming loose, despite a physician's order for weekly dressing changes. The Medication Administration Record (MAR) inaccurately documented a dressing change on 03/16/2025, which did not align with the actual observation. The Infection Preventionist confirmed the lack of a nurse-physician discussion about the midline's status. Resident 21 was admitted with a double lumen midline used for IV electrolyte administration. The midline dressing was dated 03/09/2025, with ends coming loose, and the MAR inaccurately documented care on 03/16/2025. The Clinical Nurse Manager confirmed the discrepancy and described the dressing as not appearing new. The Director of Nursing acknowledged the lack of a specific midline policy and confirmed that the facility followed the PICC Dressing Change policy, which required dressings to be labeled with date, time, and initials. The failure to perform midline care as documented placed residents at risk for infection, as noted by the Director of Nursing.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection control measures for a resident with an indwelling urinary catheter and an intravenous midline catheter. The resident, who was admitted with serious conditions including septic shock and pneumonia, was placed on enhanced barrier precautions as per a physician's order. However, during an observation, a therapist did not adhere to these precautions while providing care. Specifically, the therapist used gloves but failed to wear a gown when emptying the urinary bag connected to the resident's catheter. This oversight was confirmed by a registered nurse who acknowledged that the therapist should have used both gloves and a gown during the procedure. The facility's infection preventionist nurse also reiterated that enhanced barrier precautions, which include the use of gloves and gowns, should have been followed during the care of the resident's indwelling catheter. The facility's policy, aligned with CDC guidelines, mandates these precautions for residents with indwelling medical devices to prevent the spread of multi-drug-resistant organisms.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper dialysis care and communication for two residents requiring such services. For Resident 28, the facility did not maintain documented evidence of communication or collaboration of care between the facility and the dialysis center. The facility driver, who transported Resident 28, did not have the dialysis communication paper post-dialysis treatment and was unaware of the resident's contact isolation precautions, leading to potential cross-contamination. Additionally, the facility did not communicate Resident 28's infection status to the dialysis center, which could have compromised infection control measures at the dialysis center and during transport. For Resident 27, the facility also failed to maintain documented evidence of communication or collaboration of care between the facility and the dialysis center. The resident's medical records lacked documentation of pre- and post-dialysis vital signs and weights, as well as care orders and management for the resident's arteriovenous fistula (AVF). The facility did not obtain, transcribe, or implement care orders for monitoring the AVF for signs of bleeding, infection, and drainage until several days after the resident's admission. The Infection Preventionist and Director of Nursing confirmed the lack of communication and documentation regarding dialysis care for both residents. The facility's policies and agreements with the dialysis center emphasized the importance of communication and collaboration of care, but these were not followed, leading to potential risks for the residents' health and safety.
Failure to Obtain Physician Order and Care Plan for Splint
Penalty
Summary
The facility failed to ensure a physician order was obtained for the use of a splint, care orders on how to manage the resident's splint were transcribed and implemented, and a care plan was initiated for one resident. The resident was admitted with a wrist fracture and had a splint in place, but the medical records lacked documented evidence of a physician's order, instructions for managing the splint, and a care plan. The resident's splint was identified during an evaluation by the Certified Occupational Therapy Assistant, but it was not included in the therapy treatment plan, and the nursing staff did not obtain the necessary physician order or care plan for the splint's management. The Director of Nursing confirmed that the admission nurse was responsible for obtaining the orders for the splint, which were missed and not transcribed. The splint was in place at all times, but no care orders had been obtained or transcribed, and no care plan had been initiated. The facility's Splint Management Policy documented that splints would be applied per physician orders, but this was not followed in the case of the resident, leading to the deficiency.
Failure to Obtain Physician's Order for IV Insertion and Care
Penalty
Summary
The facility failed to ensure a physician's order for peripheral intravenous (IV) insertion and care orders were obtained, transcribed, and implemented for one resident. Resident 138 was admitted with diagnoses including urinary tract infection, sepsis, and dehydration. The nursing progress notes documented the initiation of IV fluids, but there was no documented evidence of a physician's order for the IV insertion or related care. On observation, the IV heplock appeared old and undated, with the dressing edges peeling off, and the resident reported that the IV access had been in place for four days without use. A registered nurse confirmed the absence of an order for IV access insertion or related care and noted that the IV heplock was old and the dressing was undated and peeling off. The resource nurse and the director of nursing indicated that any IV access required an order for insertion and management, including flushing and monitoring of the insertion site. Facility policies also documented the need for a physician's order for IV therapy, maintenance, and removal of any peripheral IV catheter that is no longer essential.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to ensure the Oxygen (O2) flow rate was followed as ordered or the titration rate and frequency of the administration were clarified for Resident 137. Resident 137 was admitted with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic pulmonary edema. The physician's order specified O2 per nasal cannula at 2 liters per minute (LPM) to maintain SpO2 of more than 90%, with the possibility to titrate or discontinue O2 as tolerated. However, the order did not specify whether the O2 should be administered continuously or as needed, nor did it provide titration rate parameters. Observations on multiple occasions revealed that Resident 137 was receiving O2 at 4 LPM, contrary to the prescribed 2 LPM. The resident was unsure of the amount of O2 being received and indicated dependency on O2, with no signs of respiratory distress noted during the observations. A Registered Nurse (RN) confirmed that the O2 was flowing at 4 LPM and acknowledged that the active order did not specify continuous administration or titration parameters. The RN explained that the physician's order should have been followed to avoid potential O2 toxicity. The Director of Nursing (DON) also indicated that O2 administration required an order and that staff were expected to verify and follow these orders. The DON acknowledged that the titration parameters and frequency should have been clarified. The facility's Oxygen Administration policy stated that O2 should be administered in accordance with a physician's order, with appropriate safety precautions to ensure safe administration.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was below five percent, resulting in an error rate of 6.25%. One incident involved a registered nurse administering a standard iron tablet instead of the prescribed delayed-release iron tablet to a resident. The nurse was uncertain about the difference between the two forms, and the pharmacist later confirmed that the standard iron tablet has quicker absorption compared to the delayed-release form, which releases iron gradually in the intestines. The Director of Nursing acknowledged the error and indicated that the correct dosage form should have been verified to prevent such medication errors. Another incident involved a registered nurse preparing and offering a Lidocaine 4% patch to a resident, who preferred to receive it later after therapy. When the patch was eventually administered, only one patch was applied instead of the two patches ordered by the physician. The Director of Nursing indicated that licensed nurses were expected to verify the order prior to administration to ensure the correct dosage was administered. The facility's policy on medication errors emphasized following the six rights of medication administration to minimize errors.
Unsecured Medication Carts and Resident Information
Penalty
Summary
The facility failed to ensure resident personal information was protected and that medication carts were secured. On 05/22/2024 at 2:10 PM, a medication cart near a resident's room was observed unattended with the computer screen on, displaying resident pictures and names, and the cart was unlocked. The nurse admitted to leaving the cart and computer screen unattended while obtaining supplies. Similarly, on 05/22/2024 at 8:21 AM, a registered nurse left a medication cart unlocked and unattended in the hallway while administering medication in a resident's room. The computer screen on the cart was also left on, displaying resident information, and was visible to anyone passing by. Both nurses acknowledged the importance of locking the medication cart and securing the computer screen to protect resident privacy and prevent unauthorized access to medications. The Director of Nursing confirmed that the medication carts should have been locked when unattended and the computer screens secured. The facility's policies on medication storage and administration indicated that medication carts should be locked when out of view and that electronic medication administration records should be logged out before leaving the cart.
Multiple Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to discard five expired thickened orange juice containers stored in the nourishment room. The expired containers were observed on two separate occasions, and the Nutritional Services Director confirmed the expiration dates and acknowledged that expired food items needed to be discarded to prevent foodborne illnesses. Additionally, a Cook was observed eating next to the food tray line, which is against the facility's policy. The Cook admitted to the mistake and explained that staff were supposed to eat away from the kitchen to prevent contamination. The Nutritional Services Director confirmed that staff were not to eat in the food preparation area according to the facility's policy. A Dietary Aide was observed touching their face and nose with gloved hands while handling food during the tray line. The Dietary Aide acknowledged the error and explained that, according to policy, they should have washed their hands and changed gloves after touching their face to prevent contamination. Furthermore, a soap dispenser at the sink closest to the kitchen entrance was observed empty on two separate occasions. The Nutritional Services Director confirmed the soap dispenser was empty and reported that housekeeping had been notified to provide soap. The Housekeeping Supervisor explained that staff were to request refills from housekeeping, and it was important to refill soap dispensers quickly to prevent any infection control issues.
Failure to Implement TBP and Maintain Hand Sanitizer Dispensers
Penalty
Summary
The facility failed to implement transmission-based precautions (TBP) and ensure proper use of personal protective equipment (PPE) for a resident diagnosed with ESBL and VRE. The resident, who required strict contact isolation, was transported to and from a dialysis center without adherence to TBP protocols. The facility driver, unaware of the resident's contact precautions, did not clean hands or wear PPE when assisting the resident, despite the presence of precaution signage. This lapse in protocol was confirmed by both a Certified Nursing Assistant and a Registered Nurse, who acknowledged the necessity of PPE and hand hygiene to prevent contamination and infection spread. Additionally, the facility did not maintain hand sanitizer dispensers in resident rooms, which were observed empty on multiple occasions. This issue was confirmed by a nurse and the Housekeeping Supervisor, who explained that staff were responsible for requesting refills. The lack of readily available hand sanitizer compromised the ability of staff and visitors to perform necessary hand hygiene, particularly in rooms with enhanced barrier precautions. The facility's Alcohol-Based Hand Sanitizer Policy emphasized the importance of hand hygiene to prevent infection transmission, highlighting a significant deficiency in infection control practices.
Failure to Document Resident Council Meetings and Grievances
Penalty
Summary
The facility failed to ensure a written record of resident council meetings was kept, documenting any responses to concerns raised by the Resident Council group, and a report of actions taken and the rationale to the Resident Council. Additionally, the facility did not maintain a written record of grievances, documenting any responses and the rationale for responses to grievances regarding resident issues or grievances concerning care and life in the facility. This deficiency was identified during interviews with the Administrator and a Certified Nursing Assistant (CNA), who confirmed that no meeting minutes were taken and kept by the facility, and that the facility did not have a formal grievance log. The Administrator admitted that the facility was not good at keeping up with the logs and may have copies of resident grievances. The CNA explained that the Ombudsman suggested regular monthly resident council meetings be held, and that the facility started having resident council meetings in 2023. However, the facility did not document these meetings or maintain a grievance log. The facility's Resident's Rights policy and Grievance Policy both require documentation of grievances and responses, but the facility failed to comply with these policies.
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Two residents admitted with indwelling Foley catheters did not have physician orders obtained or implemented for catheter care and management. Nursing documentation and MDS entries showed the presence of Foley catheters, but the EHR lacked orders for catheter maintenance, monitoring, or justification for continued use. One resident was observed with a full urine meter bag that had not been emptied, reported no routine cleansing of the insertion site, and had an undated, loose stabilizer, with family stating they often performed cleaning due to inconsistent staff care. CNAs and RNs confirmed the absence of catheter care orders and related documentation, and the DON verified that expected admission orders for Foley size, justification, irrigation as needed, and twice-daily catheter care were not obtained, in contrast to facility policies.
A resident with type 1 DM and insulin orders requiring MD notification for BG values outside set parameters experienced multiple episodes of hypoglycemia, including documented BG readings in the 40s. Nursing notes showed insulin was held and hypoglycemia treated, but there was no documentation that the physician was notified of these low BG values as required. Later, the resident was found unresponsive and clammy with a BG of 31 mg/dl; an RN administered oral glucose gel even though the resident could not safely swallow and the standing order required Glucagon SQ/IM for unresponsive residents with hypoglycemia. The BG remained critically low until EMS arrived and administered IV dextrose, after which the resident briefly aroused and then coded, ultimately expiring. Leadership and clinical staff confirmed that physician notification had not occurred for prior low BG readings and that the hypoglycemia treatment orders were not followed during the unresponsive episode.
A resident with type 1 DM and diabetic autonomic neuropathy was found unresponsive and clammy by a CNA during the night. An RN obtained a blood glucose of 31, administered oral glucose gel outside of order guidelines, and did not administer ordered Glucagon. A repeat blood glucose remained 31, EMS administered D10, the resident briefly regained consciousness, then became unresponsive, CPR was initiated, and the resident expired. The Administrator/Abuse Coordinator reported there was no accessible documentation of the required abuse/neglect investigation, stating that records previously maintained by the former DON could not be located and some electronic files were inaccessible after a change of ownership, contrary to the facility’s abuse/neglect policy requiring a complete, documented investigation.
A resident with multiple chronic conditions and intact cognition was sent to the hospital under an L2K after an altercation involving verbal aggression and throwing an ashtray. While the hospital later discharged the resident with a psychiatric diagnosis and arranged transport back, facility leadership had already decided, based on an unwritten practice to deny readmission for L2K cases, that the resident would not be accepted back and reassigned the bed despite available capacity. Hospital calls about the transfer were routed to case management, which confirmed the denial, and when the resident arrived with EMTs and discharge papers, staff refused readmission, did not accept the paperwork, did not provide medications, and called law enforcement, resulting in the resident being trespassed from the property even though staff knew the resident had no housing or resources. The facility had a written transfer/discharge policy allowing return after acute care but no written criteria for residents hospitalized under an L2K, and staff followed only verbal direction from leadership.
A fire response led to residents being evacuated to a courtyard while doors to the building remained closed, during which a family member, upset about not being allowed to enter, recorded a video capturing multiple residents, staff, and visitors without consent and posted it on social media with a disparaging narrative. Several residents with complex medical conditions, including COPD, cerebral infarction, tracheostomy status, Parkinson’s disease, schizoaffective disorder, dementia, and others, later recognized themselves in the widely viewed post and reported feeling upset, offended, or that their privacy was violated. Some residents and representatives noted they were not given the opportunity to consent, and one resident reported that staff told the individual to stop filming but the recording continued, contrary to facility policy prohibiting unauthorized imaging and transmission of resident images.
The facility failed to timely report two separate incidents to the state agency: a fire-related event in the main dining room and unauthorized videotaping of multiple residents by a family member. In the first incident, smoke and a burning electrical odor were observed in the main dining room, residents were evacuated, and the fire department later determined the source was a seized HVAC fan blower motor; the room was found to have only one smoke detector at the entrance, with the rest of the large space lacking detection. In the second incident, while residents were evacuated during the same code red, a family member recorded residents’ faces without consent and posted the footage on social media, contrary to facility policies that classify such conduct as a violation of resident rights and abuse requiring reporting within 24 hours. Both incidents were reported to the state agency 11 days after they occurred.
A resident with multiple comorbidities, including CHF, prior CVA, anxiety, depression, muscle weakness, and impaired mobility and coordination, was subjected to rough incontinence care by a CNA. A PT who entered the room during a brief change observed the CNA roll the small-statured resident onto their side, noted redness on the resident’s buttocks, and saw the CNA roughly wipe the area. The resident cried out in pain, stating that it hurt, but the CNA did not respond or adjust care and continued the brief change. The facility’s investigation concluded the CNA had been rough and dismissive of the resident’s expressed pain, in violation of the facility’s abuse policy.
A resident with cerebral palsy and dysphagia had an outdated and incomplete personal property inventory, despite ongoing additions of items such as clothing, plants, books, and sentimental objects. The resident’s guardian later found the resident’s cupboard completely empty, although it had previously contained food, candy, Tupperware, ceramic mugs from vacations, a soup bowl from a great grandmother, gift cards, and greeting cards from deceased relatives. Staff, including a CNA and SW, acknowledged that many belongings in the room were never added to the inventory list, and the DON informed the SW that the resident’s items had been removed and placed in a secure cabinet in preparation for a survey, with gift cards unaccounted for. This failure to maintain an accurate inventory and the removal of belongings without notifying the guardian violated the resident’s right to retain and use personal possessions.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school and told a CNA that a teacher had pulled their hair, pinched them, yelled at them, and refused to change them, while documentation also showed a 9 cm abrasion on the resident’s back after a reported school incident. The CNA immediately brought the resident to the SW, who, according to the CNA, dismissed the allegation, stated they did not believe the teacher, and referenced the resident’s history of fabricating stories, then the CNA reported the concern to the DON. The DON acknowledged being informed that the resident returned crying and soiled and notified the Abuse Coordinator, but neither the DON nor the Abuse Coordinator reported the allegation to the SA, law enforcement, ombudsman, physician, or responsible parties, despite facility policy requiring immediate reporting of any alleged or suspected abuse or injuries of unknown source.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school distressed and reported to a CNA that a teacher had pulled the resident’s hair, pinched the resident, yelled, and refused requested care. The CNA brought the resident to the SW, who expressed disbelief in the allegation, characterized the resident as fabricating stories, and referenced potential school expulsion and limiting friend visits. Nursing documentation the same day noted a new 9 cm abrasion on the resident’s upper back present on return from school. The DON, who was notified by the CNA, did not interview the resident, teacher, or SW and did not review the clinical record or complete a wound assessment. The Abuse Coordinator, though aware of behavioral issues reported by the teacher, did not obtain statements, review the record, or initiate any abuse investigation, despite facility policy outlining required investigative steps for abuse and neglect allegations.
Failure to Obtain and Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and management of indwelling Foley catheters for two residents. One resident was admitted with diagnoses including polyneuropathy, acute respiratory failure, and acute pulmonary edema, and both the nursing documentation evaluation and admission MDS documented the presence of an indwelling Foley catheter. However, the medical record contained no physician orders for Foley catheter care and maintenance. On review, the DON confirmed that monitoring and maintenance orders for the Foley catheter were expected but were not present in the record. Another resident, admitted with prostate cancer, benign prostatic hyperplasia, and a recent UTI treated in the hospital where a Foley catheter was placed, was observed with a urine meter bag containing 350 ml of urine that had not been emptied that morning. The resident and family reported that the Foley catheter had not been replaced since admission and that the insertion site was not routinely cleansed, with the family often providing cleaning due to inconsistent staff care. A CNA confirmed the urinary bag was full and should have been emptied at the start of the shift, and noted the catheter stabilizer was undated and loose. Review of the EHR by RNs showed no care or management orders for the indwelling catheter since admission and therefore no documentation of routine catheter care. The DON confirmed that admission orders for Foley size, justification for use, irrigation as needed, and twice-daily catheter care, including cleaning around the insertion site and emptying the bag, had not been obtained or entered, resulting in no documented catheter care in the MAR, contrary to facility policies requiring valid justification and admission assessment with communication to the physician.
Failure to Notify Physician of Recurrent Hypoglycemia and to Follow Hypoglycemia Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to protect a diabetic resident from neglect when nursing staff did not follow physician orders for monitoring and responding to hypoglycemia and did not notify the physician of critical low blood glucose (BG) values. The resident had type 1 diabetes mellitus with circulatory complications and diabetic autonomic neuropathy and was ordered multiple insulin regimens, including Lantus and sliding-scale Insulin Aspart, with explicit instructions to notify the physician for BG less than 80 mg/dl or greater than 350 mg/dl. The resident also had PRN orders for oral glucose gel for BG less than 70 mg/dl with symptoms of hypoglycemia if able to swallow, and for Glucagon to be given SQ or IM for BG less than 70 mg/dl with signs of hypoglycemia when the resident was unable to swallow or was unresponsive. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. On two separate dates prior to the fatal event, the resident experienced documented episodes of hypoglycemia with BG readings below the ordered parameters. A progress note documented that on one date the resident’s Lantus was held due to a blood sugar of 46 mg/dl and that Glucagon was administered, with a plan to recheck. Another progress note documented a low blood sugar of 47 mg/dl prior to breakfast, after which the resident was given juices and other fluids and the BG increased to 103 mg/dl. During this second episode, staff discussed with the resident the concern about hypoglycemia and suggested contacting the provider to lower the Lantus dose, but the resident declined changes and staff planned to remind the next shift to offer midnight snacks. The clinical record, however, lacked documentation that the physician was notified of these BG readings below 80 mg/dl, despite the physician order requiring notification for BG values outside the specified parameters. On the night of the fatal incident, a CNA found the resident unresponsive and clammy. An RN assessed the resident and obtained a fingerstick blood glucose of 31 mg/dl. Despite the resident being unresponsive and unable to drink or eat, the RN administered one tube of oral glucose gel, which was not in accordance with the physician’s order that specified Glucagon for hypoglycemia in residents who were unable to swallow or unresponsive. A repeat BG 20 minutes later remained 31 mg/dl. Emergency Medical Services were called, and when they arrived, the resident’s BG was 19 mg/dl. EMS administered D10, after which the resident briefly became arousable and then became unresponsive again, leading to CPR and subsequent death. Facility leadership, including the DON and CNO, confirmed that the physician had not been notified of the earlier low BG readings and that Glucose gel was inappropriately used instead of Glucagon when the resident was unresponsive, constituting a failure to follow physician orders and a failure to report changes in condition as required by facility policy and job descriptions.
Failure to Document Investigation of Neglect-Related Hypoglycemic Event and Death
Penalty
Summary
The deficiency involves the facility’s failure to provide documented evidence of a thorough investigation into an incident suspicious for neglect involving Resident #8. Resident #8 had diagnoses including type 1 diabetes mellitus with circulatory complications and diabetic autonomic (poly) neuropathy. According to the Facility Reported Incident (FRI), a CNA found the resident unresponsive and clammy at approximately 1:00 AM. An RN assessed the resident, obtained a blood glucose result of 31, and administered oral glucose gel outside of order guidelines instead of administering the prescribed Glucagon per physician order. A repeat finger-stick blood glucose remained 31, EMS was called, and EMS administered 10% Dextrose. The resident briefly regained consciousness, then became unresponsive again, CPR was initiated by EMS, and the resident expired. The Administrator/Abuse Coordinator stated there was no documentation of the facility’s investigation of this incident. The Administrator/Abuse Coordinator reported that the former DON had the investigation documentation, but it could not be located in the former DON’s office, and many electronic files were inaccessible following a change of ownership in February 2026. This lack of available documentation was inconsistent with the facility’s Abuse, Neglect, and Exploitation policy, which required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, and providing complete and thorough documentation of the investigation.
Failure to Readmit Hospitalized Resident Under L2K and Lack of Criteria for Psychiatric Holds
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was readmitted following a hospital transfer under a legal hold (L2K) and the absence of written criteria or policy governing residents hospitalized under an L2K. The resident had multiple medical diagnoses, including diabetes mellitus with long-term insulin use, chronic right lower leg ulcer, cellulitis, infective myositis, muscle weakness, difficulty walking, reduced mobility, pulmonary embolism, hypertension, chronic pain, and anxiety disorder, and had an intact cognition score (BIMS 15/15). After a resident-to-resident altercation in the smoking area, during which the resident was verbally aggressive and threw an ashtray, the physician ordered an L2K and the resident was transferred to the hospital. Facility staff, including the DON and RN, described the L2K as used when a resident was a danger to self or others and confirmed the resident was sent out under an L2K. Hospital records documented that the resident’s behavioral symptoms stabilized in the emergency department, were assessed as secondary to psychiatric illness, and that the resident remained a danger to self and unable to care for self, with ongoing psychotic behavior noted. The hospital ultimately discharged the resident with a diagnosis of acute situational disturbance and arranged transportation back to the facility. Prior to the resident’s return, the hospital made multiple calls to the facility about the transfer, which were routed to case management; the receptionist reported being informed by case management and the marketing director that the facility would not readmit the resident. The marketing director stated that facility practice was to deny readmission for residents sent out under an L2K and that the decision not to readmit this resident was made in advance based on direction from the administrator, after which the resident’s bed was reassigned despite available capacity in the building. When the resident arrived back at the facility with EMTs and hospital discharge papers, staff informed the resident that readmission would not occur, that belongings had been packed, and that the previous room was occupied. Staff did not contact the hospital for clarification because the resident did not want to return to the hospital. The facility did not accept the discharge paperwork, did not provide medications, and did not readmit the resident, with the DON stating there were no physician orders and that residents sent to the hospital were considered discharged once admitted. Law enforcement was called, the resident was issued a trespass notice, and was escorted off the property, despite the facility’s awareness that the resident had no home, no local family, and no resources. The resident reported staying at a nearby bus stop for several days without food, money, or medications, and later presented to the hospital with worsening leg swelling and a confirmed DVT after not receiving prescribed medications. The facility’s existing transfer and discharge policy stated that residents transferred to an acute care setting were permitted to return upon discharge, and the DON confirmed there was no written policy governing L2K or hospital readmissions, with staff following only verbal direction from leadership.
Unauthorized Social Media Video of Residents During Fire Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ privacy rights were protected when an unauthorized video recording of residents during a fire response was made and posted on social media. During a Code Red related to smoke from the dining room ceiling, residents were evacuated to the outdoor courtyard while doors to the facility remained closed under the fire protocol. A resident’s family member, upset about not being allowed to enter from the courtyard, began video recording the scene, capturing multiple residents, staff, visitors, and minors without consent. The 45‑second video was then uploaded to social media with a narrative criticizing the facility’s handling of the event and referring to residents in a disparaging manner, and it subsequently received extensive public engagement in the form of comments, likes, and shares. The facility identified approximately 20 residents who were present in the courtyard and appeared in the video, including residents with significant medical conditions such as acute on chronic respiratory failure, COPD, cerebral infarction, encephalopathy, gastrostomy and tracheostomy status, protein‑calorie malnutrition, bilateral above‑knee amputations, cerebral palsy, seizure disorder, schizoaffective disorder, Parkinson’s disease, pleural effusion, bipolar disorder, atrial fibrillation, polyneuropathy, and dementia. Several residents personally confirmed being evacuated to the courtyard during the incident and later recognizing themselves in the posted video. One resident reported witnessing a staff member instruct the person filming to stop, but the individual continued recording despite this direction. Multiple residents and resident representatives reported feeling upset, offended, or violated by being recorded and included in the social media post without their consent. Some residents stated they would have wanted the opportunity to give or withhold consent, and others expressed that the filming and posting were inappropriate and that they took offense to the situation. Public guardians and family members of residents with dementia or under guardianship also expressed disapproval of their residents being recorded without consent and used in a social media video. The facility’s own policy on videotaping, photographing, and imaging of residents states that transmitting unauthorized images of any resident via internet or social media is a violation of residents’ rights and that any such image or recording that may be construed as humiliating or demeaning is considered resident abuse and must be reported and investigated, underscoring that the incident constituted a failure to protect resident privacy and dignity.
Failure to Timely Report Fire Incident and Unauthorized Resident Videotaping
Penalty
Summary
The facility failed to timely report to the state agency a fire-related incident that occurred in the main dining room. On 03/08/2026 at 12:50 PM, a maintenance assistant observed smoke coming from a ceiling vent in the main dining room along with a burning electrical odor, activated the fire alarm, and staff evacuated residents to the courtyard while the fire department responded. The fire department determined the source was a seized HVAC fan blower motor whose belt generated smoke briefly until failure, with no fire, heat, injuries, or suppression activity. During the investigation, the surveyor observed that the 3,363 square foot main dining room was protected only by a single photoelectric smoke detector at the entrance providing egress coverage, with the remainder of the space, including the tray ceiling, lacking detection, which appeared inconsistent with NFPA 72 (2010) Section 17.7.3.2.1. The facility did not submit a report of this incident to the state agency until 03/19/2026, which was 11 days after the event. The facility also failed to timely report an incident of unauthorized video recording and social media release involving multiple residents. On 03/08/2026, during the same code red for unidentified smoke in the dining room and while residents were evacuated to the outdoor courtyard awaiting clearance from the fire department, a resident’s family member recorded unauthorized video footage that included residents’ faces without their consent and later posted this footage on social media. Staff and resident interviews, review of social media footage, and facility documents on 03/20/2026 confirmed the unauthorized videotaping and social media release. The facility’s policy on videotaping and photographing residents, dated 10/01/2021, stated that transmitting unauthorized images of any resident via email, internet, or social media is a violation of resident rights and that any images or recordings that may be construed as humiliating or demeaning are considered abuse, which should be reported and investigated as such. The facility’s abuse policy defined exploitation as taking advantage of a resident for personal gain and required that incidents of abuse be reported to the state survey agency no later than 24 hours if they did not result in serious bodily harm; however, the facility did not report this incident to the state agency until 03/19/2026, 11 days after it occurred.
Failure to Protect Resident From Rough and Painful Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during incontinence care. The resident had multiple medical conditions, including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of the right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and lack of coordination. During a brief change in the resident’s room, a Physical Therapist entered after knocking and announcing therapy and observed the CNA roll the small-statured resident onto their side. Upon removal of the brief, the therapist noted the resident’s bottom appeared red. The Physical Therapist then observed the CNA roughly wipe the resident’s bottom, after which the resident verbalized, “ow, that hurt.” The CNA did not respond to the resident’s expression of pain and continued changing the brief without acknowledging or addressing the resident’s discomfort. The facility’s investigation, as described by the Administrator, determined that the CNA had been rough with the resident during the brief change and was dismissive of the resident’s verbal call out when the resident felt pain. This conduct was contrary to the facility’s abuse policy, which states that each resident has the right to be free from abuse, including physical abuse or mistreatment, and that the facility would implement processes to ensure residents are not subject to abuse by staff.
Resident Belongings Removed and Poorly Inventoried Without Notification
Penalty
Summary
The deficiency involves the facility’s failure to respect a resident’s right to retain and use personal possessions and to maintain an accurate inventory of those belongings. The resident, who had cerebral palsy, a developmental motor disorder, and dysphagia, was admitted with an inventory list that included clothing, an E‑Reader/iPad, a backpack, a stuffed animal, hair accessories, a wheelchair tool kit, a bathing suit, an iPad stand, a wheelchair, and cushions. The most recent inventory list on file was dated in 2023 and did not reflect all of the resident’s belongings. Staff, including a CNA and the SW, acknowledged that many items present in the resident’s room, such as plants, books, stuffed animals, lotions, blankets, clothing, jackets, nightlights, and pictures, were not documented on the inventory sheet, and that the list was “quite bare” and required updating. The resident’s Guardian reported arriving to find the cupboard in the resident’s room completely empty, although it had previously contained food items, candy, Tupperware, ceramic mugs from vacations, a soup bowl from the resident’s great grandmother, approximately $75 in gift cards, and greeting cards from deceased relatives. The Guardian was not notified that these items had been removed and filed a grievance about the missing property. The SW later learned from the DON that staff had removed the resident’s belongings from the room and placed them in a secure cabinet due to an upcoming survey, and that the gift cards could not be located. The facility’s own policies stated that all personal effects were to be inventoried upon admission and that all items subsequently brought into the facility were to be added to the inventory form, but this was not done for this resident, and belongings were removed from the room without prior notification to the Guardian or documentation on the inventory list.
Failure to Report Alleged School Abuse of a Resident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency (SA) as required. A resident with spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder returned from school after being picked up due to behaviors. Alert progress notes documented that upon return, the resident was calm and toileting was performed, during which the resident reported to a floor CNA that a teacher at school had abused them, specifically by pulling their hair, pinching their arm, yelling at them, and refusing to change them when requested. The resident became emotional and cried while making this report. The CNA immediately took the resident to the Social Worker (SW) and reported the allegation in the resident’s presence. According to the CNA’s account, the SW disregarded the resident’s report, stated they did not believe the teacher would do what was claimed, and characterized the resident’s account as a fabricated story. The SW also told the resident that if they had another behavior, they would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA then left the SW’s office with the resident and reported the concerns to the DON. A nursing progress note from the same day documented that the resident had an incident at school in which they slid partially out of their wheelchair and scraped their back, resulting in a 9 cm abrasion on the upper back. In subsequent interviews, the CNA reiterated that the resident had reported the teacher pulled their hair, pinched their underarms, yelled at them, and refused to change them, and that the resident stated they were being abused. The CNA stated they notified the DON and later reported the concern to the ombudsman. The SW, when interviewed, described being responsible for case management and acknowledged that abuse allegations should be reported to the Abuse Coordinator or DON and then to the SA, and identified various forms and signs of abuse. The SW recounted a prior incident in which the resident had alleged the teacher hit them first, but the SW believed the resident was not an accurate historian and considered the statement confabulatory. The SW confirmed there was documentation of a 9 cm abrasion on the resident’s back and acknowledged the note indicated the resident returned from school with an injury. The DON stated uncertainty about the process for abuse investigation and reporting, including not being sure who the designee for the Abuse Coordinator would be. The DON reported being told that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON stated they immediately notified the Abuse Coordinator but did not report the concern further. The Abuse Coordinator/Administrator defined abuse and neglect and stated that the facility would be responsible for reporting any allegation of abuse, neglect, exploitation, or misappropriation to law enforcement, the ombudsman, the SA, the physician, and responsible parties, regardless of whether it occurred inside or outside the facility. The Abuse Coordinator acknowledged being notified of the resident’s increased behaviors and being told the resident kicked at the teacher, but was unaware of the resident’s allegation that the teacher hit them first until informed later by the SW. The Abuse Coordinator confirmed that no reports had been made to law enforcement, the ombudsman, the SA, the physician, or responsible parties after being notified of the alleged abuse. The facility’s abuse policy required the Administrator or DON to notify the SA, ombudsman, child protective services, and law enforcement when an alleged or suspected case of neglect, injuries of unknown source, or abuse was reported, but this did not occur in this case.
Failure to Investigate Resident’s Allegation of Abuse by External Caregiver
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident #6 after the resident reported being abused by a school teacher. Resident #6, who had spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder, returned from school on 02/10/2026 and was documented as calm and collected initially. Alert progress notes recorded that after toileting, the resident told a floor CNA that the resident was being abused by the teacher, naming the teacher and describing hair pulling, arm pinching, and yelling. The resident became emotional and cried while reporting this to the CNA. The CNA immediately took Resident #6 to the Social Worker (SW) with the resident present. According to the CNA’s account and documentation, the SW disregarded the resident’s report, stated disbelief that the teacher would do what was alleged, and characterized the resident’s account as a fabricated story. The SW also told the resident that if the resident had another behavior, the resident would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA and resident then left the SW’s office, and the CNA reported the concerns to the DON. The CNA did not speak with the Abuse Coordinator at that time but documented the experience in the electronic health record and later reported the concern to the ombudsman. A nursing progress note from the same date documented that the resident returned from school with a 9 cm abrasion on the upper back, described as resulting from sliding partially out of the wheelchair and scraping on a pedestal. In subsequent interviews, the SW stated that if notified of an abuse allegation, the SW would report it to the Abuse Coordinator or DON and that abuse included physical and verbal abuse and neglect. The SW recounted that about a month prior, the teacher had reported the resident hit and kicked the teacher, and the resident had responded that the teacher hit the resident first; the SW believed the resident had no physical marks and considered the resident an unreliable historian. A behavior progress note effective 02/10/2026 documented that the SW found the resident’s statement about the teacher hitting first to be confabulatory. The SW acknowledged feeling sorry for the teacher, not believing the teacher would hit the resident, and confirmed that the resident’s right to visit a friend was not contingent on behavior. The SW also acknowledged the note indicating a 9 cm abrasion on the resident’s back and initially believed the resident fell off the toilet, despite documentation that the injury was present upon return from school. The DON reported uncertainty about the abuse investigation and reporting process, including not being sure who the designee for the Abuse Coordinator would be. The DON stated that on the day of the incident, the CNA reported that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON did not interview the resident, the teacher, or the SW, and did not review the resident’s electronic health record after being notified of the alleged abuse. The DON was unaware of the alert notes and nursing progress note documenting the new abrasion and acknowledged that a wound assessment should have been completed but was not. The Abuse Coordinator/Administrator described that an abuse investigation should include review of records, shift assignments, and interviews with residents, family, and staff, and confirmed that the facility was responsible for reporting allegations of abuse occurring inside or outside the facility. The Abuse Coordinator stated being notified only of the resident’s increased behaviors and the teacher’s report that the resident kicked at the teacher, and did not speak with anyone else about the allegation at that time. The Abuse Coordinator later learned from the SW that the resident had said the teacher hit first, but because the resident could not specify where, the SW deemed the statement unreliable. The Abuse Coordinator did not obtain written statements from the resident, CNA, SW, or DON, and did not review the resident’s clinical record. The Abuse Coordinator confirmed that no investigation into the allegation of abuse was initiated, despite facility policy requiring, at a minimum, review of the incident report, medical record, and interviews with the reporter, witnesses, resident, staff, roommate, family, and visitors.
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